PROJECT 2 Abstract Compared to other US populations, Alaska Native (AN) people face pervasive health disparities, especially for stroke. Stroke mortality rates in ANs are at least 25% higher than their White counterparts in Alaska. Stroke mortality for ANs under age 45 has increased 400%, but declined in Whites. Hypertension is the major modifiable risk factor for stroke. Improving blood pressure (BP) control requires the involvement not only of individual patients, but of healthcare systems and social environments. However, AN people face striking barriers in healthcare access. Across Alaska, 60% of residents are medically underserved, and in 75% of communities comprehensive healthcare services are accessible only by air or water. With the Southcentral Foundation (SCF), we have designed a multilevel prevention trial ? ?Blood Pressure: Improving Control among Alaska Native People? (BP-ICAN) ? that targets BP control among ANs diagnosed with hypertension. SCF uses a pre-paid, patient-centered model to provide healthcare services in Anchorage and 55 remote villages for 65,000 patients. Village residents have not participated in any past research. Using a group-randomized design, we will randomly assign 58 SCF providers to the BP-ICAN intervention or control (usual practice) condition. We will query electronic health records and sample ~10 patients per provider (total n = 500) who have a systolic BP ? 140 mmHg at 2 or more visits in the prior 18 months. Participants will receive equipment and training for home BP measurements (HBPM) to self-manage hypertension. HBPM predicts cardiovascular disease morbidity, mortality, and target organ damage better than BP readings obtained in clinics. Participant training will emphasize self-efficacy. BP-ICAN also targets therapeutic inertia ? failure to modify therapy in response to uncontrolled BP ? by facilitating patient-initiated communications about out-of-range HBPM readings. The primary outcome is systolic BP; secondary outcomes are diastolic BP; adherence to antihypertensive medication; adherence dyslipidemia and diabetes medications, if applicable; urine sodium and potassium, and changes in modifiable risk factors, including smoking, diet, exercise, lipids, blood glucose, and weight. Our study capitalizes on access to participants? electronic health records, enabling documentation of home- and clinic-based BP readings, laboratory tests, clinical events, medication changes, provider behaviors, and participant-initiated visits and communications. Our Specific Aims are: 1) at the individual level, to examine BP-ICAN?s impact on within- person change in systolic BP and secondary outcomes from baseline to 12 months; 2) at the provider level, to quantify impact on prescribing behaviors in response to participant-initiated reports or system-triggered alerts of uncontrolled BP; and 3) at the system level, to evaluate overall impact on BP control among all hypertensive patients regardless of enrollment into the individual-level intervention. BP control requires multilevel, evidence- based strategies that optimize self-care, engage providers, and use patient reported-outcomes. An economic analyses will inform the desirability of systems-wide policy changes at SCF to incorporate HBPM.